Infectious Diseases Institute at Makerere University College of Health Sciences: a case study of a sustainable capacity building model for health care, research and training

The Infectious Diseases Institute (IDI), established in 2001, was the first autonomous institution of Makerere University set up as an example of what self-governing institutes can do in transforming the academic environment to become a rapidly progressive University addressing the needs of society This paper describes the success factors and lessons learned in development of sustainable centers of excellence to prepare academic institutions to respond appropriately to current and future challenges to global health. Key success factors included a) strong collaboration by local and international experts to combat the HIV pandemic, along with b) seed funding from Pfizer Inc., c) longstanding collaboration with Accordia Global Health Foundation to create and sustain institutional strengthening programs, d) development of a critical mass of multi-disciplinary research leaders and managers of the center, and e) a series of strong directors who built strong governance structures to execute the vision of the institute, with subsequent transition to local leadership. Conclusion Twenty years of sustained investment in infrastructure, human capital, leadership, and collaborations present Makerere University and the sub-Saharan Africa region with an agile center of excellence with preparedness to meet the current and future challenges to global health.


Introduction
The Infectious Diseases Institute (IDI) at Makerere University was established in 2001 through a public-private partnership at Makerere University Faculty of Medicine in Uganda, involving a group of fourteen like-minded and foresighted Ugandan and North American clinician scientists named the Academic Alliance for AIDS Care and the Government of Uganda 1,2 . Key leaders of this Alliance included Dr. Merle Sande*, President of the AA Foundation and Chair of Medicine, University of Utah, Nelson Sewankambo, Dean of the Faculty of Medicine at Makerere University, and Henry "Hank" McKinnell, and the Academic Alliance realized that as anti-HIV drugs became more widely available in sub-Saharan Africa, it was essential to create a strong cadre of well-trained doctors, nurses, and laboratory workers who could not only administer these drugs and care for HIV-infected people but also could train others to deliver an equally high level of care. They further realized that building a center of excellence in East Africa at Makerere had the potential to produce a multiplier effect not only regionally but perhaps across the entire continent of Africa. A vision of the IDI crystallized; a center of excellence squarely focused on training, clinical care and research.
The IDI was envisioned to train tens of thousands of medical professionals who in turn would each train hundreds who would diagnose, treat, and care for the tens of millions who needed help. A bold ambition indeed. Part of that vision was to reject the idea of "good enough for Africa." Everything the IDI did from building construction to clinical research, to the laboratory, to patient care would be "world class." Moreover, the goal was African-built and African-led, an even bolder ambition. While many from other continents contributed to the IDI's success, that bold ambition has been realized. The key success factors and lessons learned with the IDI, as described in this paper by several IDI founders, provide an informative roadmap to create strategic partnerships with academic institutions in low-and middle-income countries (LMIC) to respond to current and future challenges in global health.
Key success factors for development of a self-sustaining and productive center of excellence, such as IDI, at an academic institution in LMIC are described below. a) Strong collaboration by local and international experts to combat the HIV pandemic: The AIDS crisis hit San Francisco hard in the early 1980s. As Chief of Medicine at the San Francisco General Hospital Dr. Sande, often described as an "impatient visionary", to- The partnership of IDI with the Accordia Global Health Foundation (the successor to the Academic Alliance Foundation) grew exponentially stronger as IDI launched overcome the burden of infectious diseases in Africa by building centers of excellence and strengthening medical institutions. Accordia was committed to the creation of African owned and African led permanent centers that develop health leadership, skills, and knowledge to create generations of healthy children and adults. Key personnel at Accordia included Warner C. Greene MD, PhD, liance, Carol Spahn, Executive Director, and Kelly Willis, Vice President and Director of Programs. Accordia worked closely with IDI to build vibrant programs. A Visiting Professor-In-Residence series, the Sewankambo review involving international leaders in infectious disease, Gates funding to better understand how to train mid-level health workers to care for HIV infected people, and new funding for recruitment of IDI leadership and annual conferences bringing together 13 leading centers in Africa to share lessons learned and the best approaches to accomplish their mission of building stronger organizations more effectively for the delivery of healthcare. IDI was a center point of these discussions and steadily grew as a sustainable and effective model for all of Africa. Accordia merged with Africare in 2017.

b) Purposeful public-private partnerships and cooperate responsibility to combat global health challenges:
of Directors to become Chairman/CEO early in 2001. Hank's belief was that companies' success needed to be measured by the trust and respect of all stakeholders not ers extremely well up until that time and was one of the pharmaceutical industry generally were far from the most knew that criticism was unfair and set as one of his goals tious disease advisory board of 20 of the world's most respected academic researchers (the IDAB). Their advice was " a better story to tell".
program at the IDI. Hank realized health care in Africa was delivered in several different ways. The private market was separate from government-run healthcare in many medicine for patients with HIV and cryptococcal meningitis at no charge to the government while maintaining successful and saved many lives.

c) Bold ambitions and visionary leadership:
Hank also served on President George W. Bush's Presidential Advisory Council on HIV/AIDS (PACHA) and knew President Bush was committed to providing help to Africa in dealing with the triple threats of HIV/AIDS, Malaria, and Tuberculosis. Hank further realized that medical aid was not like food aid. Medicines could not just be handed out from the back of a truck. Supported by the ease Control and prevention (CDC), and in particular Dr. Merle Sande and Hank met with the Presidents of South Africa, Kenya, and Uganda, seeking a public sector part-was President Museveni and the government of Uganda", said Hank. That decision was strongly supported by Dr. Merle Sande who as a young clinical research doctor had done pioneering work in Uganda and had made many friends there. Dr. Sande brought on board Dr. Nelson Sewankambo. d) Autonomy within a reputable University: Governance of an autonomous institute (www.idi-makerere. com) through an independent IDI Board allowed IDI to limited to land, technical expertise, established academic programs and the University brand. IDI is headed by an Executive Director (ED) with the support of a 14 -member senior management team (a head and deputy head for 6 programmes and 2 sub-programmes plus a head and deputy head for 3 support functions). The ED reports to a Board with 12 members who are selected on their the Board. The Board provides strategy and policy oversight and meets a minimum of 3 times a year to review progress and to provide recommendations for progress-nance Committee, with other ad hoc committees such as the nominations committee formed as and when needed. Board members serve for a four-year renewable term and are rotated away at the end of the second term to create room for new board members. The Board nominations committee scouts globally for potential candidates for nomination to the IDI board and to the ED position. The Board reports annually to the Annual General Meeting (AGM) of members. The members, who are the apex governance body of IDI are the University Vice Chancellor and University Secretary; and through the AGM cial position and its progress in achieving its mission. The of new nominees to the Board and ED positions.
By having a full-time executive director and independent projects, with presence in different parts of the country. Through its independent recruitment processes, IDI is able to hire technical and support staff as core staff and research staff, as and when required. IDI staff have increased from 28 core staff in 2004 to 2058 in 2022 ( Table  2). Results from multiple studies are published in reputable peer-reviewed journals 4-8 , with over 940 peer-reviewed publications over the past two decades. These results have led to programmatic improvements and improved outcomes of HIV treatment and management of co-infections country-wide; thereby amplifying the college of e) Seed funding: greatly facilitated the establishment of infrastructure, governance and management systems. Apart from direct ed grants totaled about $25,000,000 from FY2005/2006 (when IDI was transferred to Makerere University and started maintaining its own accounts to FY 2011/2012). enabled the institute to grow its programmatic areas: and subsequently the outreach program (later renamed Health Systems Strengthening), Laboratory Services, and the more recently added Global Health Security (GHS), Academy for Health Innovation, and HIV prevention research site (IDI Kasangati). f) Capacity building and mentorship for science leadership: The IDI attracted several capacity building programs to educate and train scientists who are able to innovate local solutions to local problems of global importance including HIV/AIDS, tuberculosis, malaria, hepatitis B, Ebola, and more recently COVID-19. Overall, IDI has contributed to training of 31 PhD and 63 over 563 trainees (different cadre) in short courses includ- (Table 1). Through capacity building programs including the initial two-year fellowship in Infectious Diseases and the institute developed its leaders including the current executive director, Andrew Kambugu, the current Principal of MakCHS, Damalie Nakanjako, and others who are leading several departments and research groups at the college of health sciences 3 . Through co-mentorship with scientists in collaborating academic institutions in the USA and Europe several doctoral trainees, post-docs and fellows have been supported at the IDI which is now an international training site for Fogarty training programs (D43 and U54 funded by the National Institute of Health, USA) and European and Developing Countries Clinical Trials Partnership (EDCTP), among others.  There is still a need to build capacity for research with animal models to promote further understanding of genetics and pathogenesis of human diseases and related innovative therapies in sub-Saharan Africa.  IDI has trained over 51,799 health workers from Uganda and other African countries in infectious disease prevention and treatment, laboratory skills and various aspects of systems strengthening ( Figure 1). The training department provides systematic ongoing distance support, eHealth approaches and a free call-in service for both patients and health care providers, and has informed government policies for HIV-infected patients. In addition, IDI supports nation-wide health systems strengthening (HSS) with programmes that address key functions across the World Health Organization (WHO) health system pillars (such as HR management) using an HIV platform. IDI is currently one of the lead implementing partners for the US US Centers for Disease Control and Prevention (CDC)/ Ministry of Health. The institute currently supports care and treatment in 14 districts in the Kampala and West Nile Regions, covering over 270,000 people living with HIV (approximately 20% of all PLHIV in Uganda). Notably, IDI was selected by the US National Institutes of Health (NIH) to host the African Centre of Excellence in IDI to take part in the global data science revolution to advance Computational Biology and big data analysis concepts to manage current and future epidemics.

IDI TRAINING PROGRAMME
South-South collaborations: IDI has various ongoing relationships with over 10 African institutions. These include University of Zimbabwe, Moi University, Ifakara Health Institute, University of Cape town, University of the Witwatersrand, and Neurologic Association of South Africa, which are either subgrantees or co-implementers of various projects and the East, Central and South African College of Physicians (ECSACOP) for which IDI opment founding Partner of Afrehealth, a Pan-African health inter-professional and multi-disciplinary organization established in 2016 with US NIH support in partnership with IDI. The Afrehealth network, whose Secretariat is In Kwame Nkrumah University of Science and Technology (KNUST) in Ghana has over 500 individual members (26 countries) and 46 academic institutional members from 18 countries (across all geographic and linguistic regions of Africa). IDI co-implements a num-ber of projects with Afrehealth. Similarly, IDI was selected by the Africa Union and, Africa CDC with the support of MasterCard Foundation to lead the Implementation Science pillar of the Saving Lives and Livelihoods (SLL) Programme -an unprecedented $1.3 bn commitment for the African continent by Mastercard Foundation. Through its Program for Research on Vaccine Effectiveness (PROVE), IDI will support the Africa CDC to estimate the real-world effectiveness of COVID-19 vaccination on the entire African continent, understand the barriers and enablers of COVID-19 vaccination in Africa and to evaluate the Impact of COVID-19 vaccination on national health systems. Implementation of country PROVE grants shall inform COVID-19 vaccination rollout programmes across the African continent.

Lessons learned
• Strategic partnership of leading scientists in Infectious diseases supported the national and regional response to the HIV pandemic  • At the time, 2001, the HIV disease burden was overwhelming therefore illness/disease care became the primary goal. Although Public Health and preventive care is the most effective, strategic, and least costly way to promote better health and save lives, many people tend to wait until they are disabled, ill, or near the end of life before realizing that the illness/disease could have been prevented/avoided.
• Within the IDI, Makerere University hosts: a) Clinical and basic scientists at all levels to attract funding for research and training programs, b) strong local and international collaborations and networks, c) strong and reputable research support infrastructure, d) state-of-the art physical infrastructure with research laboratories and data systems to understand disease epidemiology, e) ability to conduct translational science locally, and f) a global health security program.
• Through collaborative efforts in an environment that promotes academic freedom, many people contributed to development of the IDI at Makerere University and remain so proud of what has been accomplished. . • Makerere University has learned great lessons from IDI and its development, and has gone ahead to approve the creation of over ten other progressive self-governing institutes of the University to provide similar supportive environments that motivate staff to be very productive. In this regard Makerere is providing leadership and direction to other universities on the continent on how to be innovative and do business differently.
"The creation of IDI opened a new chapter to the University regarding how it should do business differently. If the University takes the lessons from IDI at heart, Makerere would be a very different place in the next 10 years and I hope I can live to see that transformation" said Nelson Sewankambo, one of the fourteen founder members of the Academic Alliance "IDI is continuing to transform Makerere, the health system and policy landscape, and impacting peoples' lives, the friends of IDI", he added.

Conclusion
Twenty years of sustained investment in infrastructure, human capital, leadership, and collaborations presents Makerere University and the sub-Saharan Africa region with an agile centre of excellence with preparedness to meet the current and future challenges to global health. ongoing annual support by the Government of Uganda, Makerere University institutional support, as well as numerous local and international collaborations have collectively led to the sustained productivity of the IDI in national and regional response to emerging infectious disease challenges.